Section 4 - Management of diagnosed conditions

1. What is chronic obstructive pulmonary disease (COPD)? ^1–3

• A lung condition characterised by chronic respiratory symptoms (dyspnoea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis, emphysema) that cause persistent and progressive airflow obstruction
• The primary contributing factor is exposure to tobacco smoke. See Smoking cessation
• All comorbid chronic conditions increase the risk of poor lung function and death

2. Diagnosis of COPD ^1–3

• A diagnosis should be considered in any patient who has:
  • a history of recurrent lower respiratory tract infections
  • exposure to tobacco smoke or occupational or environmental dusts, vapours, fumes and gases
  • breathlessness that is persistent, progresses over time and worsens with exercise
  • chronic cough and sputum production +/- recurrent chest infections
  • forced expiratory post-bronchodilator FEV₁/FVC ratio < 0.70 (airflow limitation)
• Some people present with worsening breathlessness, a cough +/- sputum production or limitation to activity
• Identifying the airflow limitation and symptoms helps to classify COPD severity. See Table 1. to determine:
  • its impact on patient health
  • the risk of future exacerbations, hospital presentations or death
  • management and treatment

3. Management of COPD ^1,2

• Management goals are to:
  • reduce symptoms to improve exercise tolerance and health status
  • reduce risk of exacerbations to prevent disease progression and mortality
  • encourage those who smoke to stop. See Smoking cessation
  • identifying and addressing comorbidities, in particular:
    • any respiratory conditions including Asthma (adults and children > 12) and Bronchiectasis, any cardiac conditions including Heart failure, Hypertension, and Rheumatic heart disease
    • Diabetes
    • Osteoporosis

1. Support patient self-management ^1–3
   • Support the patient with lifestyle modification with particular attention to
     Smoking cessation and pulmonary rehabilitation. See 3.13 Pulmonary rehabilitation program
   • Provide COPD education (Resource 1.) and discuss:
     • airway clearance and breathing techniques. See Resource 2.
     • medicine usage, effects and compliance
     • develop a COPD action plan. See below
   • Refer patient to SMoCC, a phone service that supports patients manage their condition. See Resource 3.
   • Encourage the patient to identify barriers to adequate lifestyle modification and
     medical adherence and create goals to overcome those barriers. See Engaging our patients
2. Social-emotional support ^2,3
   • See Social-emotional wellbeing
3. Action plan ^1–3
   • Develop an action plan (Resource 4.) with the patient so they can:
     • recognise and monitor exacerbations and severity. See Table 1.
     • intervene early to prevent exacerbations
     • understand and feel comfortable using it
   • Review and update action plan each visit, especially when changing medicines
4. Minimising occupational exposure ^1–3
   • Discuss minimising exposure to occupational (particularly mining and quarry workers) risk factors including:
     • smoke, gases, vapours and fumes
     • biological and mineral dusts
     • diesel exhaust
     • indoor and outdoor pollutants and chemicals
5. Monitor health status ^1–3
   • According to 5. Cycle of care, regularly monitor:
     • temperature, pulse, respiratory rate, blood pressure, pulse oximetry
     • weight and BMI
     • sputum colour and amount
     • lung function by spirometry before and 10–15 minutes after 4 puffs of salbutamol via a spacer. See Resources 5.
     • ECG for Coronary heart disease changes and right ventricular strain pattern
     • chest x-ray for Bronchiectasis, emphysema, lung hyperinflation, heart failure
     • echocardiogram for pulmonary hypertension
     • swallowing difficulties. Refer to speech pathologist
   • Use the COPD Assessment Test (CAT) to measure the impact of COPD on the patient and changes over time. See Resource 6.
6. Smoking cessation ^1–3
   • Quitting smoking is the most effective means to prevent COPD from progressing
   • Perform spirometry on past or present smokers with recurrent respiratory infections or frequent and unusual sputum production. See Resource 5. and 7.
   • See Smoking cessation
7. Improve exercise tolerance ^1–3
   • Encourage patient to keep as active as possible to maintain lung function
   • Refer to a pulmonary rehabilitation program. See 3.12 Pulmonary rehabilitation program
   • See Physical activity and sleep
8. Nutrition ^1–3
   • Lung disease increases the risk of poor nutrition, weight loss and reduced muscle and bone strength due to:
     • increased energy needs
     • changes in appetite
     • lack of energy to shop, cook or eat meals
     • an increased need for essential vitamins, minerals and antioxidants
   • Refer to dietitian if there is weight loss or weight gain
   • For unintended weight loss, refer to exclude an alternate diagnosis e.g. cancer, diabetes
   • See Diet and nutrition
9. Sleep hygiene ^1–3
   • Medicines, breathing difficulties, anxiety and depression in COPD can disrupt sleep
   • Patients with COPD and OSA have:
     • a higher prevalence of pulmonary hypertension than those without OSA
     • improved survival outcomes and lower rates of hospital admission with CPAP use
   • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 8.
10. Prevent respiratory infections ^1–4
    • Respiratory illnesses contribute to COPD exacerbations and progression
    • Provide Influenza, pneumococcal, pertussis and COVID-19 vaccines as per the  Australian Immunisation Handbook
11. Home oxygen ^1–3
    • Long term oxygen therapy (18 hours/day) reduces cardiac workload and prolongs survival in patients who have chronic resting arterial hypoxemia:
      • FEV₁ < 40% predicted
      • SpO₂ < 88%
      • those with pulmonary hypertension
      • PaO₂ ≤ 55 mmHg or SpO₂ ≤ 88%
      • PaO₂ 55–59 mmHg or SpO₂ with evidence of right heart failure, pulmonary hypertension or high red cell count
    • Home O₂ is evaluated by blood gases after 4–8 weeks when the person is stable, to ascertain effectiveness and whether to continue
    • Medical Aids Subsidy Scheme (MASS) can supply home oxygen to eligible patients. See Resource 9.
    • Provide a home visit for oxygen concentrator education
12. Prevention of complications ¹
    • Identify risk factors for Osteoporosis by assessing:
      • vitamin D levels
      • mobilisation
      • use of high dose corticosteroids
      • underlying decreased bone mineral density
      • bone densitometry where appropriate
    • Assess Australian cardiovascular disease risk calculator
    • Pulmonary hypertension:
      • is difficult to treat
      • manifests late due to poor lung ventilation from ongoing exacerbations
      • management relies on smoking cessation, improving diet and physical activity and medicine adherence to prevent right heart failure
13. Pulmonary rehabilitation program ²
    • Offered to all symptomatic patients with more than 2 exacerbations per year or with moderate to severe COPD to avoid hospitalisation
    • Refer to the Pulmonary Rehabilitation Toolkit. See Resource 10.
    • Refer to an exercise physiologist or the Lung Foundation for rehabilitation program details and/or training. See Resource 11.
14. Airway clearance technique
    • An early intervention strategy to clear lung secretions and avoid hospitalisation:
      • start with 5 deep abdominal breaths. Expand chest fully, starting with the
        diaphragm and lower ribs. Avoid lifting or shrugging shoulders
      • do 30–60 seconds of relaxed breathing. Breathe from the diaphragm. With a hand feel the stomach rising and falling. Shoulders should be relaxed
      • do another 5 deep abdominal breaths
      • follow this with 30–60 seconds of relaxed breathing
      • take a medium sized breath in and huff the air out a little more forcefully
      • start with 3 cycles of gentle huffs. Finish with 2 cycles of more forceful huffs
      • finish with a cough to clear any secretions left in the main airways
      • repeat the cycle 2–3 times or until no more secretions can be removed
    • Refer to a physiotherapist if patient is unable to clear lung secretions
    • For airway clearance information see Resource 2.
15. Falls prevention
    • Screen for individual falls risk. See Resource 12.
    • Refer to a balance and strength group by a physiotherapist or exercise physiologist
    • Refer to an occupational therapist to assess for home modification requirements to minimise trip and fall hazards
16. Palliative support ^1–3
    • Consider discussing a palliative approach to care, advance care planning, and end-of-life issues when patient has:
      • predicted FEV₁ < 25%
      • dependence on oxygen
      • respiratory or heart failure or other comorbidities
      • weight loss or muscle wasting
      • decreased functional status with increased dependence on others
      • advanced age
      • See Palliative care and Advance Care Planning
    • Refer to physiotherapist or occupational therapist for a home support assessment e.g. wheel chair, bedding, rails etc
    • Refer eligible patients to Home and Community Care (HACC) and MASS services. See Resource 9.

Table 1. Stepwise management of stable COPD ^1–3,6

4. Medicines for COPD

• Monitor medicine adherence and correct inhaler technique according to product instructions. See Resource 13.

• See Table 1. for a guide to manage stable COPD

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. Better living with Chronic Obstructive Pulmonary Disease A Patient Guide and The Lung Foundation resources
2. Airway clearance resource
3. Self-Management of Chronic Conditions (SMoCC) service
4. Lung foundation COPD action plan or for Aboriginal or Torres Strait Islander people
5. The spirometry handbook and training tools and the COPD and spirometry resources
6. The COPD Assessment Test (CAT)
7. COPD screening using spirometry
8. The Epworth Sleepiness Scale and STOP-Bang questionnaire
9. Access the Medical Aids Subsidy Scheme (MASS) and Queensland Community Support Scheme
10. The Australian Lung Foundation Pulmonary Rehabilitation Toolkit
11. The Lung Foundation training and education website
12. Individual falls risk screening and Queensland Government’s Stay on Your Feet Toolkit
13. Lung Foundation inhaler use videos and printable instructions and the National Asthma Council